Insured:

* Required fields

* First Name: * Last Name: * Date of Birth:

First Name: Last Name: Date of Birth:

* Address:

* Home Phone: * Work Phone: Fax:

E-mail: Occupation:

* Losses? Date, Type and Amount paid:

* Years of boating experience:

Length and make of previous boats owned:

Courses and memberships: USPS USCG ASA ACBS Yacht Club Other

Vessel:

* Year: * Manufacturer:

* Length: * Model:

Hull material: Fiberglass Wood Steel Aluminum Max speed of vessel: No. of engines: HP (each):

* Engine Manufacturer: Fuel: Diesel Gas Type: Inboard Outboard Inboard/Outboard

Vessel purchase date: Purchase Price:

Mooring Location:

Summer: Winter:

Navigation: Atlantic Gulf Great Lakes Chesapeake Pacific Bahamas Caribbean Other If Navigation is "OTHER", enter type here:
Inland Waters (State of): Lay up from to

Coverages:

* Hull & Equipment: $ Deductible: 1%   2%   Other

P&I Liability: $300,000 $500,000 $1,000,000 Paid Crew?: No Yes If Yes, how many?

Trailer: $ Tender/OB: $ Survey Available: No Yes Survey Date:
Present Insurance Company:
Expiration date: Premium:
Breach of Warranty Coverage: Yes No     Amount: